Framingham Criteria Predict New Hypertension Better Than Prehypertension in Young Adults

September 20, 2013

FRAMINGHAM, MA — A prediction model based on Framingham Heart Study criteria was sharper than having prehypertension at identifying young adults who went on to develop new hypertension over the next 25 years, in an analysis published in the journal Hypertension[1].

"Risk-prediction models that go beyond the prehypertension classification may be used to better identify young adults with an increased risk of hypertension, who may benefit from the adoption of preventive measures early in life," according to the authors, led by Dr April P Carson (University of Alabama at Birmingham).

The Framingham model relied on a composite of age, sex, body-mass index, smoking, systolic blood pressure (BP), and parental history of hypertension in predicting incident hypertension. It underestimated hypertension risk in the analysis until the model was recalibrated using data from the population studied, 4388 participants in the prospective Coronary Artery Risk Development in Young Adults (CARDIA) study.

Prehypertension was defined according to standard JNC-7 criteria as systolic BP 120 to 139 mm Hg or diastolic BP 80 to 89 mm Hg.

Carson et al argue that risk stratification for later onset of hypertension that relies on one risk factor may not be discriminating enough to be useful clinically, especially if prehypertension is to be considered a target for drug therapy, as has been advocated. The condition "may not be the best risk-stratification tool, with 28% of adults meeting prehypertension criteria," they observe.

"Given the unsettled issue on whether pharmacological therapy should be prescribed for individuals who meet prehypertension criteria, the findings from the current study suggest that better characterization of individuals at risk for hypertension based on the assessment of multiple factors is needed to develop appropriate prevention and treatment strategies."

In the current analysis, participants were aged 18 to 30 (mean 25) at their baseline evaluations in 1985 and 1986; they were followed up every five years for 25 years. They lived in four urban regions in the US; 49% were African American, and the rest were white.

C Index (95% CI) for Incident Hypertension in the CARDIA Cohort, by Race

Prediction Model


African Americans



0.84 (0.83–0.85)

0.81 (0.79–0.82)

0.87 (0.86–0.89)


0.71 (0.70–0.73)

0.69 (0.67–0.71)

0.73 (0.71–0.75)

The Framingham-based model was superior to the prehypertension model at discriminating the 1179 persons who developed new hypertension during the follow-up, overall and solely among African Americans or whites, from those without incident hypertension.

"The ability to identify young adults at high risk for hypertension will provide the opportunity to efficiently apply risk-reduction interventions in addition to population-based approaches for the prevention of hypertension," the group wrote.

The study was supported by the National Heart, Lung, and Blood Institute. The authors had no disclosures.


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